Which Surgery Should I have?

There have been nearly a dozen different weight loss surgeries that have been offered over the last fifty years.  Many of these procedures have been phased out in favor of less invasive, more effective options.  There is a lot of debate and discussion about the different surgical options available.  These discussions are often dominated by the zealots who favor one operation over all others.  The most and least successful patients tend to be the most vocal, so we are often presented with a view of the best and worst aspects of each surgery, when the chances are, your results will likely fall somewhere in the middle.  

When you listen to someone’s account of their experiences with Bariatric Surgery, or read an online post, it’s critical that you remember that the results after surgery vary from person to person.  Some patients have remarkable results after surgery and find themselves easily maintaining their weight loss for the rest of their lives, while others struggle.  Some easily adapt to their new lifestyle while others find it hard to let go of old habits.  The genetic, emotional, physiological and biochemical reasons behind this variation are very poorly understood.  Even after millions of procedures, we have very few tools that help us predict who will succeed after surgery and who will not.  Within the next five to ten years, I believe that we will develop blood tests or other diagnostic studies that will allow us to more accurately guide patients on their likelihood for success after surgery.  Until then, we have to accept that your success after surgery is difficult to predict.  There are some things that you can do to improve your chances, but there are many other factors that are beyond your control.  We must work hard to modify factors like your post-operative diet and exercise program, but also learn to accept and love ourselves if we don’t meet all of our weight loss goals.

I always caution my patients about making a procedure choice based on one person’s experience with a surgery.  We all know going into Bariatric Surgery that complications and difficulties after surgery can occur.  We also know that it is possible to not reach your weight loss goals or regain your weight years down the road.  If you have a friend who had a great experience with a sleeve gastrectomy, then you may too, but you also might not.  As human beings, we are very drawn to people’s stories to help us make sense of confusing decisions.  Following a friend or loved one through the surgery and watching their recovery and ultimate success is very comforting when you make your own decision, but it’s critical that you remember that stories, both good and bad, may distract you from making your best decision.  

For instance, you may have a friend who has constant nausea and abdominal pain after a gastric bypass procedure.  You suffer from diabetes and are looking for the best surgery to get you off insulin (which is a gastric bypass), but are concerned after watching your friend’s negative experience.  However, you may be missing an important piece of the puzzle – your friend is a smoker and has continued to smoke after the procedure, while you are not a smoker.  Most patients who smoke after a gastric bypass procedure suffer from frequent nausea and abdominal pain – in my practice, I refuse to perform gastric bypass procedures on any patients who haven’t quit smoking well before surgery and acknowledge the difficulties they will have if they start again after surgery.  Although your friend has had a terrible time after her surgery and urges you not to make the same mistake, her experience is unlikely to be relevant to yours.  There are so many nuances that determine someone’s experience after surgery, basing your decision on a few other’s experiences may lead you down the wrong path.

I also think that the further out someone is from surgery, the more seriously you should take their advice.  Because weight loss success should be measured over the long run, we have to listen to the stories of those who are five or more years out from their surgery to hear the full story.  Your relationship with food is very different at five years out from surgery than it is at three months out.  We’ll discuss this in detail later, but for the purpose of deciding on the right surgery for you, try to find patients who are several years out as well as those who are still within their first year.

Perhaps one exception to my caution against basing your decision on the experience of one person is when that person is a first degree, blood relative.  If your parent, child or sibling has undergone surgery, then there is a much higher likelihood that your experience will be similar to theirs.  The reason for this is the strong impact that genetics has on your outcome after surgery.  When you watch a family member go through Bariatric Surgery, we are offered a glimpse of how your DNA will impact your results.  As I just mentioned, we don’t have any tests that can be used to assess your genetic response to surgery, but the stories of your genetic relatives are the next best things – be sure to take this into consideration if you are lucky enough to have someone you share DNA with go through the surgery.

Today, there are four procedures that are offered in the United States and paid for by the majority of insurance companies. In my opinion, for 95% of all patients, there are only two reasonable options to choose from, the laparoscopic gastric bypass and the laparoscopic sleeve gastrectomy.  These procedures both offer substantial weight loss and a favorable short term and long term safety profile.  The other two operations, adjustable gastric banding (like the Lap-Band™) and the Duodenal Switch, in my opinion, have too little reward, and too much risk, respectively.

Before we dig into the nuances of choosing between a sleeve gastrectomy and a gastric bypass, let’s first examine adjustable gastric banding and the Duodenal Switch.  If we can gain an understanding of the downsides of these operations, we’ll be able to appreciate the upsides of the sleeve gastrectomy and gastric bypass better.

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